When I was a Registrar I was lucky enough to do an MSc in Clinical Microbiology at Queen Mary’s University of London. This involved a really early morning once a week to catch a train from Nottingham to London, a two hour journey, a day of practical work and lectures, and then a two hour journey home (it was a gruelling day, gosh I was so lucky!). I learnt a lot doing the MSc and met some great people, but it was during these long train journeys that I came up with an idea about how to pass essay and short note exams. This method became known as the Seven Pillars of Waffledom, but more on why later.

How do you help your examiner mark your essays and short notes?Now this isn’t about cheating! It’s just a polite observation. During the MSc we had to write essays and short notes on various topics, it was good practice as this was also the standard format of the three hour exam papers in the “olde” FRCPath Part 1 exam; I quickly realised I had to get better at writing essays and short notes. I spoke to my Consultant Supervisors who used to mark these exam papers and they all said the same thing, “make sure your answers are clear and easy to read”. “Is that it?” I replied grouchily. Simply put yes it is, because if you write clearly and legibly your examiner is more likely to look favourably on your essay and may give you the benefit of the doubt with some of your answers. If your answer is illegible and disorganised or if it takes too long to decipher your answer, then they will not be so kind and you won’t get the mark. How long do you think it takes to read an essay and how long extra should they allow to read a badly written one?! This may seem unfair but it is human nature… it’s also a good lesson for clinical work, good communication is really important and that includes your written communication.

​Another important lesson for me was that these essays and short notes usually involved closed marking; that is the examiner had a specific list of points they were looking for in the essay or short note. So you could wax lyrical about whatever you liked but if you didn’t put down the key points they were looking for you would get no marks.

So how do you write an essay or short note that hits those keys points and helps your examiner mark a question?

My solution was to write under headings in a report format rather than giving pages of prose. I would then use either short paragraphs or bullet points to make each individual point. In this way I was helping my examiner to see everything I knew without burying it in long paragraphs of text. I also didn’t waste time trying to work out how to beautifully structure my sentences or link my paragraphs into a long unnecessary story. It was purely factual. And if I did put down a piece of information they didn’t want to see they could go past it quickly and get to what they did want to see.

In order to do this I needed to know what my headings were for each essay before I wrote it; and this didn’t mean “acquiring the question” before the exam! What I needed was a clear essay plan that I could “learn” before I actually took the exam. But surely one size doesn’t fit all?! I hear you cry…

​Essay and short note plansAs you look at past exam papers you start to realise there are only a limited number of types of question you can be asked. The subject can vary but the types of essays repeat. This is a really important thing to realise as it means you only need to be able to remember a small number of “essay types” into which you slot your knowledge at the time of writing.

Let me explain with the original “seven pillars” I came up with which I could then write some knowledge or waffle about. For example, if you are asked to write an essay or short notes on a particular bacterium there are seven headings you should write under including the kind of things to write in each section:

Pathogenesis – how does it cause infection, what are its main virulence factors?

Laboratory Diagnosis – how is infection diagnosed, how is the bacterium identified?

Clinical Manifestations – how does infection with this bacterium present?

Treatment – how are the infections treated?

Prevention and Control – vaccination, prophylaxis, infection control procedures, public health

If you were to cover all of these aspects of a particular bacterium in an essay or short note then you would score very highly. Try it; using E. coli or Staphylococcus aureus apply what you know to this structure and see how it fits.

​Why seven headings?​Because short lists are easier to remember than long lists and seven is often considered the optimum number of things we as humans can easily remember (although I did occasionally stretch the number to eight or nine if needed).You can produce these types of plans for any infectious organism; bacteria, fungus, viruses and parasites. You can also then expand it out to antimicrobials, antimicrobial resistance and clinical scenarios.

So that’s the easy bit, what about other essay types?I think the breakthrough for me came when I realised that what appeared to be more complicated essays were in fact all very similar, and standard essay plans could be adapted to help answer more difficult questions.

For example an essay might ask you to explain how you are going to investigate an outbreak of a specific infection such a Hepatitis C on a dialysis unit. Argh panic where to start!!! OK calm down… the essay plan might look like this:

Establish case definition

Confirm cases are real

Confirm outbreak and determine extent

Examine descriptive epidemiological features of the cases

Generate hypotheses

Test hypotheses

Collect and test environmental samples

Implement control measures

Interact with the press and write a report

A more detailed example of how this works for a specific essay on a Pseudomonas aeruginosa outbreak can be found here.

Now what if the essay said “you are a new consultant and the Chief Executive of your Hospital tells you the rate of Clostridium difficile is too high and he wants you to write a report saying how this should be tackled”. Argh! Don’t panic… On the face of it this might appear a different question but when you break it down your “outbreak” essay plan still applies:

Establish case definition – what is C. difficile and how are cases diagnosed, what constitutes a case?

Confirm cases are real – how will you test for C. difficile and confirm cases?

Confirm outbreak and determine extent – initiate a surveillance program to detect cases

Examine descriptive epidemiological features of the cases – look at surveillance data and undertake root cause analysis of cases to see if there are common factors

Generate hypotheses – based on common factors devise a plan to tackle those factors which appear to be driving C. difficile cases e.g. antimicrobial use, poor infection control practices, etc.

Implement control measures – factors shown to be successful should be expanded out through the hospital, and teaching and education undertaken to make this common practice

Interact with the press and write a report – present the findings of the new program to the Trust and ensure good practice becomes embedded in the Trust philosophy

So there you have my secret to writing essays and short notes. You still have to do the book work to know the facts to write down, but this method helps you make the best use of those facts. And I think it works.

​Whilst revising I read various books and papers to gain knowledge but I made sure every day that I read and learnt the essay and short note plans. I had them printed on post cards and in spare moments I would quickly read through them. The evening before and on the day of the exams when everyone was trying to cram in those last morsels of knowledge, I sat and read through my plans.

When I sat down with my exam papers I read all of the questions before starting and decided which questions I was going to answer. I then ordered them from easy to difficult and started with those I considered easiest to get some marks under my belt as well as give me more confidence and time to tackle the harder ones. I then picked my first “easy” question and jotted my “seven pillars” in the margin. I then started writing.

Here’s a big tip!If I couldn’t think of anything to write under a heading the first time through I would just write the heading, leave at least half a page, and then come back to it at the end; I could usually by this point write something even if it was just “there is no vaccination against x, there is no role for prophylaxis and there are no specific infection control precautions”… it might be worth a mark or two?! On one occasion I was struggling to remember how we diagnose Cryptosporidium spp. infection, but I had time to come back to the blank space on the page, in my mind I went around the enteric lab “looking” at all of the equipment and “asking” why it was there. When I got to the UV microscope I remembered, Cryptosporidium spp. are acid fast and we used an auramine stain to detect it… Bingo! I filled in the space I’d left.

So finally why did this become known as the “Seven Pillars of Waffledom?” Well I was explaining my “original seven headings essay plan” approach to a friend on the MSc when she said, “oh like the 1922 book Seven Pillars of Wisdom by T.E. Lawrence (of Arabia)!” I said “kind of…but I think sometimes I may waffle more than provide wisdom!” She laughed “oh so you’re saying it’s the microbiological Seven Pillars of Waffledom, which will help me pass the MSc and my FRCPath exams!?” It wasn’t long before the “Seven Pillars of Wisdom” became permanently the “Seven Pillars of Waffledom” and the name stuck. (Editorial note: David can waffle on pretty much any topic, as long as he has a structured plan!)

Whatever you want to call them, here (these print to postcard size 4x6 inches) are the different types of essay and short note plans I came up with, and I hope they are as useful to you as they were to me. Incidentally, I also wrote Microbiology Nuts & Bolts in the same way using standard and consistent headings for each type of section (under editorial guidance!) so it is easier to remember the facts in the book.